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r <br /> I <br /> 1 <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: / 7/7 S0 u1A �14o-ST.57V41�27rI PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Califomia Business and Professions Code and my license is in full force and effect. <br /> License* C 7- t! 165- Exp Date: r l3�/2ai <br /> Date: <br /> f l Contractor - l(i <br /> Signature: >d <br /> r Title: <br /> Print Name: 01--� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit Is issued. <br /> I have andwill maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:_,!CY _ Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor C , 1 shall forthwith comply with those provisions. <br /> Exp, Date: Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL. PENALTIES AND CIVIL FINES UP To 6100,000, IN ADDITION TO THE COST OF COMPENSAnON,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE. <br /> T A FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-37 licensed authorized representative), <br /> hereby authorize(print name) Po';-4 A-Jrrbft-P'dno sign this San Joaquin County Well & Bering Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is timited to the worts <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP', <br />